Guest post: Remember the basics

By Kelly Harney, RN, BSN, MA, CCDS

When I was trained in CDI, ACDIS didn’t exist. I had no encoder to use. There was hardly anyone I could turn to and run a case by. We were a group of 10 case managers, all educated on the fundamentals of coding, the reasons behind CDI efforts, and what opportunities to look for by body system. We had our notes near each diagnosis in the DRG Expert, under nearly all DRGs, and taught to look for possible specificity to move our diagnosis into the correct major diagnostic category (MDC) and DRG. This was all before the introduction of the three-tiered MS-DRG system with CC/MCCs in 2007.

As is often the case, the combined CDI/case management model did not work out in the long run. We were pulled in too many directions and CDI was left by the wayside. There were providers looking for action on a safe discharge plan, nurses wondering what time the pickup would be, and families taking as much as we could give. On the insurance side, there were approvals to get and reviews to give. There was equipment to arrange, nursing and subacute rehab to set up. And to top it all off, administration wondering why our case mix index was flat.

That’s when I was approached by my director at the time (now a VP with that organization) and asked if I would be willing to take on responsibility of CDI on my own. Needless to say, I jumped at the chance. I loved this job then and still have the same passion for it now. I have learned more aspects of medicine/surgery and disease process in this job than I could have ever imagined. Not one day has gone by that I haven’t learned something new, and that’s the aspect that I love the most.

Today, I want to remind ACDIS Blog readers about some of the basic training we’re received over the years. I think, and have always said, that anyone can find a low sodium. Physicians don't need us for that, they need us to help paint the true picture of the patient’s condition and their reason for needing clinical help—regardless of which healthcare setting you work in.

As an example, take a look at this case.

A 67-year-old man was admitted with rhabdomyolysis and a creatine kinase (CK) of 5,000. He arrived at the hospital after a fall that left him on the floor for several hours (not days). After careful study, it was noted that this was not the first fall of the day, much less the week. He had fallen five times that week and he noted that he didn’t know why but his legs kept “giving out.” This history was given around day two. He was initially placed in observation. An exam was performed and neurology was called to give input regarding the patient’s legs giving out. On further examination, it was also noted that he had been having some urinary issues as well. An MRI was ordered after the neurologist confirmed the patient’s findings on exam. The MRI showed a spinal tumor at the cauda equina level that was compressing the patient’s spinal cord. A neurosurgical consult was written and I’m sure most CDI professionals can guess what the plan was.

Either diagnosis would meet the definition of principal diagnosis by Official Guidelines for Coding and Reporting, but I always like to drive it back to the “after study” portion of the Uniform Hospital Discharge Data Set rule. Why was the patient in the hospital? The issues with ambulation were certainly a huge factor in the admission, increased nursing care, length of stay, discharge plan, placement, evaluation, monitoring, and treatment. My advice here would be to follow the neuro/NS notes. I often like to chase the specialty to figure out the body system that the case belongs in.

Since the treatment was focused initially on the rhabdomyolysis and re-hydration to correct it, it was coded to the rhabdomyolysis. Interestingly, when the order to admit was written, the reason was listed as neurosurgery consult. After discussion with the coding professional, she agreed that the neuro issues should “run the case.” 

Situations like this play out all the time in CDI and coding departments all over the country. That’s why we have jobs at all. Sometimes CDI professionals pick up on a particular nuance of a case, sometimes the coders bring back something from the discharge summary that we might have missed. We need to look at the totality of the information we have at hand and do our best to ensure that information best represents the care required for that patient.

Editor’s note: Harney is a clinical documentation quality integrity auditor at Providence St. Joseph Health/Mission in Irvine, California. Contact her at Kelly.harney@stjoe.org. Opinions expressed are that of the author and do not necessarily represent HCPro, ACDIS, or any of its subsidiaries.